SPOTLIGHT
Training Nurses Increases Implant Use in Ghana
Between 1998 and 2003 more than 600 nurses in Ghana received training to provide Norplant implants (84, 103). Now more than 88,000 women have used or are using implants (47). Training nurses, as well as some doctors, was crucial to increasing access to implants and reducing waiting times for clients (23). The large number of providers trained to provide Norplant will make it easier for Ghana to start providing the new implants. The Ghana Health Service collaborated with EngenderHealth, a technical assistance organization, to carry out the training. The U.S. Agency for International Development (USAID) provided funding and supplies.
Ghana’s previous policies implied that only doctors could insert implants. As a result, women seeking implants often encountered long waits or found that the doctor was unavailable. EngenderHealth staff documented these difficulties, and this helped to convince policy makers to clarify the guidelines in 1996. Ghana’s national family planning guidelines now explicitly permit nurses to provide implants (23, 103).
The training was directed to nurses instead of doctors because more nurses were available, nurses were more likely to stay in their communities, and nurses were more motivated to learn insertion and removal procedures. By comparison, doctors tended to have too much to do and were less interested in learning implant procedures (79). Initially, only a few doctor/nurse teams received training each year, starting in 1994. Widespread training of nurses started in 1998, after Ghana clarified its policies (23).
By building training capacity within Ghana’s health system, EngenderHealth and the Ghana Ministry of Health sought to assure that the training effort would be sustainable. EngenderHealth trained Ghana Health Service staff, who, in turn, trained providers to insert and remove Norplant (23).
In addition to teaching technical skills, the Ghana Health Service trained an even larger number—almost 2,800 nurses —in counseling and interpersonal communication skills for all family planning methods, including implants (23). As a result, a national survey found that providers encouraged new clients to ask questions or share concerns about methods during 71% of visits in 2002, compared with 31% of visits in 1993 (41).
The Ghana Health Service also promoted facilitative supervision, an approach that emphasizes mentoring, joint problem solving, and two-way communication between the supervisor and those being supervised. By playing a supportive, friendly role, supervisors helped providers improve various skills. For example, at first only 25% of providers said that their supervisors examined records and gave feedback, or observed them providing services. After the training this increased to 75% for both indicators (23). One supervisor summarized, “People are now happy to see me and no longer try to hide away…. We sit down and discuss issues. I make suggestions on how staff can solve their problems” (48).
Following the training, many more facilities offered implants, and 88,000 women had implants inserted (47). The number of facilities offering Norplant grew from 23 in 1994 to 168 by 2002 (23). The percentage of women of reproductive age using implants across the country increased from 0.1% in 1998 to 1.2% in 2006 (47).
Ongoing Challenges Include Staff Turnover and Stock-Outs
Training is an ongoing effort. In 2003 the trainers began to conduct refresher courses in Norplant removal (84). Depending on the caseload in a particular clinic, providers sometimes do not get enough practice performing removals to maintain their skills. Also, many providers leave the country or stop practicing, taking their new implant skills with them. Between 1996 and 2002 the number of doctors and nurses in Ghana decreased by 17% and 24%, respectively (23). As staff turnover occurs, trainers can educate the new staff, sometimes with on-the-job training, when courses are not possible (51).
Ensuring a constant supply of implants is another challenge. The Ministry of Health of Ghana recognized the importance of reliable supplies and earmarked a small amount of its budget for Norplant, beyond USAID’s contributions (79). Still, problems with distribution and ordering have led to local shortages. In 1998 there were stock-outs of Norplant in almost every region (23). In 2002, while 17% of the facilities that provide family planning services in Ghana offered implants, almost one-third of these did not have implants available on the day that they were surveyed (30) (see Meeting Demand for New Implants Requires Supply and Access).
Emerging challenges include funding and training for the transition to one or more of the new implants. Norplant will soon be discontinued, and USAID funding for Ghana’s national family planning program ended in 2004, although some district-level funding continues (51, 79). In 2005 the Ghana Food and Drug Board approved Jadelle (84). The trainers received training in Jadelle in early 2007. In several regions trainers are now training providers to offer Jadelle. The Ghana Health Service is making plans for the transition to Jadelle in other regions (51). For the short term Ghana has secured funding from other donors to purchase Jadelle, but the need for support will continue (79).
Many African Women Will Choose Implants When Available
Attempts to introduce implants in Africa have often failed because trained providers, adequate supplies, and awareness of implants have been lacking (79). Levels of use remain low in most of Africa. In countries such as Ethiopia, Kenya, and Tanzania, however, implant use is increasing (14, 42, 78). The experience of Ghana and other countries shows that many African women will choose implants when there are trained providers and implants available.
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